PRP for Tiers

Let's Get Started!

We are very excited to start generating new PRP patient referrals for your practice. Before we can begin developing your new profile website, we need to learn a bit about yourself and your unique practice!

For optimal conversion rates and increased web traffic, we strongly recommend providing as much information about your practice as possible. All content submitted should be proprietary to your clinic, and a good representation of your practice.

For questions please call 800-775-0283 Ext. 101.

*All fields with an asterisk are required.

What phone number would you like your incoming patient calls routed to?*

This should be your primary office number so that all calls from prospective patients can be connected to your staff.

What email address would you like your incoming email inquiries from patients sent to? (You may include up to 2.)*

All online consultation requests will be automatically sent to the address(es) specified below.

Your physical office address where you currently see patients*

We will only market one location per membership, however, we can list your second location on the profile.

Street AddressCityState / Province / RegionZIP / Postal Code

Please check the box below if you have a second location.

Second Location

Address

Street AddressCityState / Province / RegionZIP / Postal Code

During business hours do you have?

Someone actively answering phones

Phone answering service

Name of the clinic.

Name of the provider.*

Is the above provider the person to be featured?*

Yes

No

Please list the provider that you want to be featured.*

Will the featured provider see patients?*

Yes

No

Please list the provider that will see patients.*

Biography for the provider(s) - you can copy and paste this information from a document or website.*

Provide the mission statement or medical philosophy of the provider or clinic.

How many years has the provider been practicing medicine?*

How many years has the provider been offering PRP to patients?

Approximately how many PRP patients has the provider treated?

Which conditions does the provider treat with PRP? Check all the apply.*

Anxiety and Depression

Back Pain

Chronic Headaches

Injuries

Joint Pain

Sexual Dysfunction

Tendon Problems

Other

*

Which PRP services does the provider offer? Check all the apply.*

Acne Scar Removal

Breast Lift

Butt Lift

Face Lift

Hair Loss Treatments

Sexual Rejuvenation

Other

*

What other services are offered?

Are free consultations offered?

Yes

No

Do you accept insurance?

Yes

No

Ownership of Intellectual Property and Trade Secrets:By signing our Subscriber Agreement, and completing this New Member form, you hereby acknowledge that you agree to our policies on intellectual property, confidentiality and trade secrets as stated in our agreement. Please refer to these sections of your subscriber agreement for further understanding of our terms and conditions. We are very diligent in enforcing these policies. Please contact us if you have any questions.

I have read and understand the terms and conditions included in my membership agreement.*

Yes

Once your form is submitted it will take our Web Development Department 7-10 business days to build your website and directory listings. Once your website and directory listings are complete, you will be notified via email by our Member Support Team.

We appreciate you taking the time to provide us with the necessary content and information.

We look forward to sending you many new patient referrals for years to come!